Topical and intralesional therapies for alopecia areata

Co-regulatory mechanisms and potential markers of oxidative stress-related genes in vitiligo and alopecia areata

BACKGROUND

The specific role of oxidative stress (OS) in vitiligo and alopecia areata (AA) remains unclear. The aim of this study was to analyze and identify the key markers of OS in vitiligo and AA by bioinformatics.

METHODS

We obtained vitiligo and AA datasets from gene expression omnibus (GEO) database. The difference-expressed genes of vitiligo and AA were identified by differential analysis, and the functions of difference-expressed genes were identified by gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Gene Set Enrichment Analysis (GSEA) enrichment analysis. Subsequently, Veen package was used to obtain the intersection genes of OS-related genes with vitiligo and AA. Finally, we used CIBERSORT to assess the infiltration of immune cells in vitiligo and AA.

RESULTS

Through enrichment analysis, we found that vitiligo and AA were mainly enriched in cell cycle and cell adhesion molecular channels. We identified KLB and EIF3C as key genes in OS regulation of vitiligo and AA, and found that KLB and EIF3C participate in disease progression by regulating T cells and neutrophils.

CONCLUSIONS

According to our findings, KLB and EIF3C play a crucial role in the progression and development of vitiligo and AA, which have been identified as biomarkers and target for early diagnosis of patients.

Comparison of Efficacy of Topical Betamethasone Dipropionate and Topical Minoxidil in Patients With Alopecia Areata

Background and objective Alopecia areata (AA) is a reiterative and nonscarring type of hair loss that can affect any hairy area of the body, particularly the scalp. It manifests as patchy or confluent hair loss with variations in demographics and ethnicity. There are numerous treatment options available, including topical and systemic steroids, topical minoxidil, dithranol, tacrolimus, psoralen and ultraviolet therapy (PUVA), contact immunotherapy, and oral immunosuppressive drugs. However, no previous contrast for efficacy is present between the topical betamethasone versus topical minoxidil alone in our population. This study aims to compare the efficacy of topical betamethasone dipropionate versus topical minoxidil in patients with AA. Methodology A nonrandomized controlled study was conducted at the Department of Dermatology, Jinnah Hospital Lahore, incorporating the data of patients between July 26, 2016, and January 26, 2017, after obtaining institutional ethical approval. One hundred patients with alopecia, either on the scalp or any other hairy part, from both genders, aged between 18 and 50 years, were included in the study. Two groups were created, and patients were assigned to these groups based on the clinician's choice. Group A patients were administered betamethasone dipropionate (0.05%) lotion twice daily on affected areas for 12 weeks. Group B patients were administered minoxidil (5%) solution twice daily on affected areas for 12 weeks. A four-week follow-up plan was followed. A five-point scale score system was used for alopecia grading. After 12 weeks, the hair regrowth score (RGS) was used to compare the efficacy of treatment between the two groups. Results A total of 100 patients with grades S1 to S3 AA of less than three months duration were enrolled. Two groups were created, with 50 patients in each group. The mean age in Group A was 29.08 ± 6.51 years, while in Group B, it was 29.38 ± 6.62 years. In Group A, there were 76% males and 24% females, while in Group B, there were 74% males and 26% females. Comparison of efficacy of topical betamethasone dipropionate versus topical minoxidil in patients with AA demonstrated a greater efficacy of 74% (Grade 3 and Grade 4 responses) in Group A, while in Group B, only 42% of patients showed efficacy. A statistically significant difference was found, with a P-value of 0.001. No serious side effects were noted. Conclusions Our study concluded that topical betamethasone dipropionate (0.05%) lotion has statistically significantly higher efficacy compared to topical minoxidil (5%) solution in patients with AA.

Effect of fractional laser alone or in combination on alopecia areata: A systematic review and meta-analysis

BACKGROUND

Alopecia areata (AA) is characterized by limited non-scarring patchy alopecia, which appears as round or oval patches and is prone to recurrence, causing severe psychological burdens to patients. No specific device has been approved by the FDA for the treatment of baldness, but new treatments are being investigated and treatments such as the excimer laser, He- Ne laser, and excimer lamp have been proposed. A growing number of studies have found that fractional lasers also have great potential in the treatment of AA.

METHODS

A literature search and meta-analysis using Review Manager 5.4 software to investigate the efficacy of fractional laser treatment for AA.

RESULTS

Fractional laser combined with minoxidil (RR 1.32, 95% CI 1.17-1.49, p < 0.00001) or cortisol (RR 1.39, 95% CI 1.15-1.67, p = 0.00006) was more effective than either drug alone in the treatment of AA. Of course, the fractional laser alone was also effective in the treatment of AA (RR 10.33, 95% CI 2.07-51.36, p = 0.004) and more effective than cortisol alone (RR 1.86, 95% CI 1.36-2.52, p < 0.00001), and there was no effect on the occurrence of adverse effects (p = 0.49 > 0.05). When compared to other physical treatments of a comparable kind, fractional laser therapy's effectiveness was not significantly different (p = 0.15 > 0.05).

CONCLUSION

Our results show that the use of fractional lasers can effectively treat alopecia areata.

A prospective study to compare the efficacy of cryotherapy versus intralesional steroid in alopecia areata

Background:

Alopecia areata (AA) is an autoimmune disease that results in the loss of hair on the scalp and elsewhere on the body. The present study was conducted to compare the intralesional steroid and cryotherapy in the treatment of AA.

Materials and Methods:

The present clinical study was conducted in the Department of Dermatology, Venereology, and Leprology, Muzaffarnagar Medical College. The simple random sampling technique was used for randomly dividing the subjects into two groups: group I (local cryotherapy) and group II (intralesional corticosteroid).

Results:

A positive response was significantly more among the intralesional steroid group (86.0%) when compared with the cryotherapy group (62.0%). There was a significant difference in relapse between intralesional steroid group (22.0%) and cryotherapy group (16.0%). An excellent response was significantly more among the intralesional steroid group (44.0%) when compared with the cryotherapy group (18.0%). Poor response was significantly more among the cryotherapy group (18.0%), compared with the intralesional steroid group (0.0%). The mean pre-treatment, post-treatment, and the change from pre- to post-treatment Severity of Alopecia Tool [SALT] were compared between cryotherapy and intralesional steroid groups using the unpaired t-test. The mean pre-treatment, post-treatment, and the change from pre- to post-treatment SALT were significantly more among the intralesional steroid group when compared with the cryotherapy group.

Conclusion:

The authors found that superficial cryotherapy could be a meaningful adjuvant treatment option for AA patients. There was a significantly less relapse rate with cryotherapy. Among the currently available topical modalities for the treatment of AA, the best response was to the intralesional steroids followed by cryotherapy.

Alopecia areata: a review on diagnosis, immunological etiopathogenesis and treatment options

Patients suffering from alopecia areata (AA) can lose hair in focal regions, the complete scalp, including eyelashes and eyebrows, or even the entire body. The exact pathology is not yet known, but the most described theory is a collapse of the immune privilege system, which can be found in some specific regions of the body. Different treatment options, local and systemic, are available, but none of them have been proven to be effective in the long term as well for every treatment there should be considered for the possible side effects. In many cases, treated or non-treated, relapse often occurs. The prognosis is uncertain and is negatively influenced by the subtypes alopecia totalis and alopecia universalis and characteristics such as associated nail lesions, hair loss for more than 10 years and a positive familial history. The unpredictable course of the disease also makes it a mental struggle and AA patients are more often associated with depression and anxiety compared to the healthy population. Research into immunology and genetics, more particularly in the field of dendritic cells (DC), is recommended for AA as there is evidence of the possible role of DC in the treatment of other autoimmune diseases such as multiple Sclerosis and cancer. Promising therapies for the future treatment of AA are JAK-STAT inhibitors and PRP.

Saline in Dermatology: A literature review

BACKGROUND

Saline, with its different concentrations, is the most used crystalloid solution in medicine. In dermatology, no large studies investigated the benefits of saline. The aim of this article is to review the different possible uses of saline in dermatology, in order to give final recommendations based on the literature review and our experience.

METHODS

We performed a literature search based on PubMed, EMBASE, WHO Global Health Library, Virtual Health Library, Web of Science, Scopus, Google Scholar, and Research gate. using the keywords: saline, physiological, hypertonic, isotonic, hypotonic, salt solution, sodium chloride, 0.9% NaCl, solvent, drug delivery, injection mixtures, diluent, sclerosant, intravenous, intralesional, injection, topical, soaks, fomentation, inhalation, alopecia, psoriasis, scars, atopic dermatitis, eczema, bromoderma, iododerma, lipodystrophy, in various combinations with the Boolean operators AND, OR and NOT. We also hand-searched textbooks.

RESULTS

Saline was used as a diluent with intralesional injection of steroids to minimize the risk of steroid-induced atrophy, being safe and free from preservatives that may precipitate steroids at site of injection and maximize their side effects. Saline has also been used after surgery, when atrophic scars take place or anticipated, and through injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.

CONCLUSIONS

The saline represents a helpful option as a diluent with intralesional injection of steroids in various dermatologic therapeutic indications. Moreover, the use of saline in this setting could help to minimize the risk of steroid-induced atrophy. We encourage the use of saline after surgery, when atrophic scars take place or anticipated. Also, we encourage a trial of saline injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.

Trichoscopy as an evaluation method for alopecia areata treatment: A comparative study

BACKGROUND

Trichoscopy is a useful tool for diagnosis and follow-up of alopecia areata (AA) patients. Both platelet-rich plasma (PRP) and intralesional corticosteroids (ILCs) are important treatment modalities of patchy AA.

AIM

Trichoscopic diagnosis of AA and monitoring the treatment response to PRP versus ILCs in patchy AA treatment.

PATIENTS/METHODS

This comparative study included 31 patients with patchy AA, divided into two groups: (group A) received ILCs while (group B) received PRP once monthly for 3 months. Evaluation was done by Severity of Alopecia Tool (SALT) score, Alopecia Areata Symptom Impact Scale (AASIS), photography, and dermoscopy.

RESULTS

There was a significant improvement in trichoscopic findings in both groups with regard to the number of follicular units per opening, black dots, broken hairs, and dystrophic changes. Final SALT score showed significant lower levels in both groups compared to baseline levels (P = .025 & P = .008). Final AASIS showed significant decrease in group B (P = .006) not in group A (P = .062).

CONCLUSION

Trichoscopy can help in the diagnosis, evaluation of the efficacy and safety of both modalities and might give a clue for treatment response. Both ILCs and PRP were effective in patchy AA treatment.

Combined intravenous pulse and topical corticosteroid therapy for severe alopecia areata in children: Comparison of two regimens

There is no universally accepted treatment for severe pediatric alopecia areata (AA). This prospective study comprised 73 patients (aged 1-18 years) with severe AA (>30% of scalp surface area): 37 received 1-day intravenous dexamethasone pulses (1-DP) and 36 received 3-day pulses (3-DP), monthly, for 6-12 months. Also, all patients applied topical clobetasol propionate under plastic wrap occlusion. Patients achieving >50% regrowth were considered good responders (GR). All patients reached short term, while 65/73 were available for the long-term follow-up (mean 33.3 ± 15.3 vs. 27.7 ± 14.3 months, 1-DP and 3-DP, respectively). Relapses during therapy were more frequent in 1-DP group. 3-DP patients were more frequently GR in comparison with 1-DP. 3-DP patients with disease duration <6 months had better outcomes. Patients without Hashimoto thyroiditis (HT) had 9.8-fold higher chance of being GR in comparison with HT patients. The best results were achieved in AA plurifocalis (AAP). No patient had severe short-term side-effects. At the long-term follow-up, 67% of 3-DP patients had stable results. Only 14.2% AAP patients experienced relapses. Patients had no long-term side-effects. 3-DP were more efficacious than 1-DP. Short disease duration and no HT were good prognostic factors. 3-DP protocol is well-tolerated, with beneficial effects and long-lasting results in severe pediatric AA.

Evaluation of platelet-rich plasma vs intralesional steroid in treatment of alopecia areata

BACKGROUND

Alopecia areata (AA) is nonscarring patchy area of hair loss. Platelets rich plasma (PRP) promotes development of new hair follicles. Dermoscopy is a diagnostic tool that helps in evaluation of skin microstructures which are not visible to naked eye.

AIM

To evaluate safety and efficacy of (PRP) vs intralesional corticosteroid (ILCs) in treatment of AA.

PATIENTS AND METHODS

This study was conducted on 80 patients of both sexes who had AA. Patients were classified into Group I treated by ILCs and group II treated by (PRP). Results were assessed by dermoscopic evaluation and by hair re-growth score (RGS) at (baseline), 2, 4, 6, 8, and 12 weeks. Patients were followed up for 6 months.

RESULTS

There was greater hair re-growth after treatment in both groups. In group I, (26) patients (65%) showed improvement >70% compared to 29 patients (72.5%) in group II. There was significant re-growth of pigmented hair and decrease in dystrophic hair (P < 0.001) by dermoscopic evaluation in both groups. The difference between both groups was insignificant (P = 0.57). At follow-up, two (5%) patients in group II had relapse compared to 10 (25%) patients in group I.

CONCLUSION

Platelets rich plasma is safe and promising therapeutic option in AA.

Best dilution of the best corticosteroid for intralesional injection in the treatment of localized alopecia areata in adults

PURPOSE

To evaluate and compare the clinical efficacy, dermoscopic results and safety of triamcinolone acetonide (TA) and betamethasone dipropionate (BD) injections at different concentrations in localized scalp and beard alopecia.

METHODS

Intralesional injection of BD or TA in three different dilutions; 1/4, 1/8, 1/12 (BD1, BD2, BD3, TA1, TA2, TA3) and Saline (control) was randomly applied to a total of 231 alopecia patches in 83 patients every four weeks in a maximum of six sessions until a hair regrowth score of 4 was achieved. The number of required sessions, sixth-month hair regrowth scores, treatment success rates and dermoscopic data were investigated.

RESULTS

The mean number of required sessions were similar and significantly lower in BD1 and TA1 being 4.21 ± 1.12 and 3.74 ± 0.99, respectively. Dermoscopic examinations revealed similar terminal hair growth rations in Saline (30.3%), BD1 (44.4%) and TA1 (42.9%). However, sixth-month hair regrowth scores, overall treatment success rates and percentage of terminal hair regrowth were similar in BD1 and TA1. However, adverse effects were more common in TA groups (24.3%) than in BD groups (10.6%) at the sixth month.

CONCLUSIONS

BD ¼ dilution (1.25 mg/dL) seems best corticosteroid for intralesional injection in the treatment of localized alopecia areata in adults.

Comparative study of intralesional steroid injection and cryotherapy in alopecia areata

Background and Objectives:

Alopecia areata (AA) is a common, non-scarring type of hair loss, affecting approximately 2.1% of the population, many modality of treatment recommended like steroid injection, topical Immunotherapy and several systemic therapies. The aim of this study was to compare intralesional steroid injection and cryotherapyoutcomes in AA.

Materials and Methods:

In an analytical-descriptive study, 120 AA patients treated with intralesionalsteroid injection and 120 AA patients treated with cryotherapy were randomly selected. These two groups matched for location, duration and size of lesion and also matched for age and gender. From March 2011 to September 2013, the effect and complications of the therapies after 3, 6, 9 and 12 weeks were assessed and results were compared between the two groups.

Results:

Mean age of patients in steroid injection group was 30.2 ± 6.8 and in cryotherapy group was 31.8 ± 7.1. Sexual distribution in both groups was 56.7% and 43.3 % for male and female, respectively. Location of disease in 80% was in scalp and 20% was in face in both groups. The time of beginning response in steroid group was 4.13 ± 2.13 weeks and in cryotherapy group was 6.14 ± 0.29 weeks, difference between two groups was significant (P = 0.001). In term of clinical response at the end of study, in steroid group,20 patients (16.7%) no response, 32 patients (26.7%), moderate response and68 patients (56.7%) had a complete response, and also in cryotherapy group was, 52 patients (43.3%) no response, 40 patients (33.3%) moderate response and 28 patients (23.3%) had a complete response. There was significant different in complete response rate and steroid injection was more effective than cryotherapy(P < 0.05).

Conclusion:

As the cryotherapy isa considerable treatment of AA, alsothis study proposes intralesional injection of corticosteroid, as a replacement of AA therapy; particularly the short-term complications are not significantly different.

Alopecia areata profiling shows TH1, TH2, and IL-23 cytokine activation without parallel TH17/TH22 skewing

BACKGROUND

Alopecia areata (AA) is a common T cell-mediated disorder with limited therapeutics. A molecular profile of cytokine pathways in AA tissues is lacking. Although studies have focused on TH1/IFN-γ responses, several observations support a shared genetic background between AA and atopy.

OBJECTIVE

We sought to define the AA scalp transcriptome and associated biomarkers with comparisons with atopic dermatitis (AD) and psoriasis.

METHODS

We performed microarray and RT-PCR profiling of 27 lesional and 17 nonlesional scalp samples from patients with AA for comparison with normal scalp samples (n = 6). AA gene expression was also compared with samples from patients with lesional or nonlesional AD and those with psoriasis. A fold change of greater than 1.5 and a false discovery rate of less than 0.05 were used for differentially expressed genes (DEGs).

RESULTS

We established the AA transcriptomes (lesional vs nonlesional: 734 DEGs [297 upregulated and 437 downregulated]; lesional vs normal: 4230 DEGs [1980 upregulated and 2250 downregulated]), including many upregulated immune and downregulated hair keratin genes. Equally impressive as upregulation in TH1/interferon markers (IFNG and CXCL10/CXCL9) were those noted in TH2 (IL13, CCL18, CCL26, thymic stromal lymphopoietin, and periostin), TH9/IL-9, IL-23 (p40 and p19), and IL-16 mediators (all P < .05). There were no increases in TH17/TH22 markers. Hair keratin (KRT) expressions (ie, KRT86 and KRT85) were significantly suppressed in lesional skin. Greater scalp involvement (>25%) was associated with greater immune and keratin dysregulation and larger abnormalities in nonlesional scalp samples (ie, CXCL10 and KRT85).

CONCLUSIONS

Our data associate the AA signature with TH2, TH1, IL-23, and IL-9/TH9 cytokine activation, suggesting consideration of anti-TH2, anti-TH1, and anti-IL-23 targeting strategies. Similar to psoriasis and AD, clinical trials with selective antagonists are required to dissect key pathogenic pathways.

[Alopecia areata]

The epidemiology of alopecia areata as well as murine models of this disease and genome-wide association studies support the concept of alopecia areata as an autoimmune disease. In addition, the genome-wide association studies have led to the identification of new potential therapeutic targets such as CTLA4; these results have already led to the initiation of clinical studies, for example, with abatacept. Currently topical and intralesional corticosteroids as well as immunotherapy with diphenylcyclopropenone are most common therapeutic approaches.

Madarosis: a marker of many maladies

Madarosis is a terminology that refers to loss of eyebrows or eyelashes. This clinical sign occurs in various diseases ranging from local dermatological disorders to complex systemic diseases. Madarosis can be scarring or non-scarring depending upon the etiology. Appropriate diagnosis is essential for management. Follicular unit transplantation has been found to be a useful method of treating scarring madarosis and the procedure relevant to eyebrow and eyelash reconstruction has been discussed. A useful clinical approach to madarosis has also been included for bedside diagnosis. The literature search was conducted with Pubmed, Medline, and Google scholar using the keywords madarosis, eyebrow loss, and eyelash loss for articles from 1960 to September 2011. Relevant material was also searched in textbooks and used wherever appropriate.